Anxiety Disorders Nursing CE Course for APRNs

ion, restlessness, and an intense quest for safety. Affective symptoms include frustration, nervousness, jitteriness, and being on edge (Chand et al., 2022).                                            

Social Anxiety Disorder

Social anxiety disorder is an extreme, persistent fear that others are judging the individual and that everyone is always watching them. This fear is so intense and debilitating that it can affect going to school, work, or managing daily life. Symptoms associated with SAD include palpitations, diaphoresis, trembling, abdominal pain, body posture changes, decreased voice volume, and an inability to make eye contact (NIMH, 2022).

Panic Disorder

Panic disorders consist of frequent and unexpected panic attacks. Panic attacks are sudden episodes of extreme fear associated with losing control, even without clear danger or a trigger. During a panic attack, an individual may feel an impending doom, like they have no control. Patients with PD may experience shortness of breath, chest pain, palpitations, diaphoresis, trembling, and fear of going crazy or dying. These symptoms may occur unexpectedly in the absence of a trigger. Individuals who experience a panic attack may not develop a panic disorder (NIMH, 2022).

Agoraphobia

Agoraphobia is a distinct diagnosis based on intense fear and avoidance that often occurs in at least two of five everyday situations and lasts more than six months. The situations may involve using public transportation, being outside the home, in a crowd or standing in a line, being in open spaces, or being in enclosed spaces alone. Individuals with agoraphobia may experience panic-like symptoms as well as incontinence or falling (Chand et al., 2022).

Obsessive-Compulsive Disorder

OCD comprises a manifold of symptoms, including rituals, intrusive thoughts, preoccupations, and compulsions. Obsessions are intrusive and unwanted repetitive thoughts, urges, or impulses that can cause an increase in anxiety or distress. The onset of this chronic disorder usually occurs in early adulthood (late teens to early twenties) but can begin to manifest during the early teenage years as well (Gupta et al., 2019). People with a family history have a higher risk of having the disorder, and slightly more women are affected than men (Skapinakis et al., 2019). There is not as much known about this disorder as others, but it is widely believed that genetic and environmental factors are involved in its development (Yildirim & Boysan, 2019).

Posttraumatic Stress Disorder

PTSD is increased anxiety and stress after exposure to a traumatic or stressful event (Boland et al., 2021). PTSD is a psychological disorder caused by a traumatic event that includes flashbacks, sleep disturbances, depressed mood, and anxiety (Denke & Denham, 2019). Patients with PTSD may display irritability or have angry outbursts with little or no cause. They may also have an exaggerated startle response (Mann & Marwaha, 2022). Additional signs and symptoms of PTSD are flashbacks, fear, sleep disturbances, nightmares, depression, and social isolation (Scott, 2019).

Some public health and safety occupations are at a higher risk of developing panic disorders, especially PTSD. PTSD involves an emotional response (severe panic and worry) that can be triggered when reminded of past events. Individuals who are at increased risk of this disorder are victims who have been sexually assaulted or raped, victims of domestic violence or abuse, children who have witnessed domestic violence or abuse, war veterans, healthcare workers, and first responders (Guess et al., 2019). Something that should be taken into consideration when working with victims of domestic violence is that often when a victim decides to leave their abuser, the domestic relations court in many states does not recognize witnessing abuse as a form of abuse. Research shows the harmful impact witnessing abuse can have on children and their brain development. Family courts may force the victim to remain in contact with their abuser if they share children or allow them to maintain some form of parental rights, which can have devastating effects on victims attempting to get treatment for PTSD (Paul, 2018).

Diagnostic Criteria

Individuals with GAD may present with physical symptoms such as chest pain, shortness of breath, diaphoresis, and dizziness (Adwas et al., 2019). The diagnostic criteria include excessive concern and worry for at least 6 months with difficulty controlling these emotions, along with three or more of the following symptoms: restlessness, feeling keyed up or on edge, difficulty in concentrating or mind going blank, being easily fatigued, muscle tension, sleep disturbance, and irritability (Adwas et al., 2019; APA, 2022). The initial assessment should begin with assessing behavior and somatic symptoms such as diaphoresis, tremors, or dry mouth. Evaluate for risk factors such as psychosocial stress, psychosocial difficulties, and developmental issues. Reviewing past medical history, psychiatric history (including trauma), and substance abuse is necessary (Munir et al., 2022). The Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire, Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale (HADS) are screening tools that can be utilized to assess for symptoms of anxiety (Boland et al., 2021).

People with GAD will exhibit extraordinary concern on most days for 6 months or more regarding various things (school, work, family). The patient describes the concern as challenging to regulate. The concern is related to at least three of the following (observed on most days for 6 months or more), which the patient reports:

• feeling tired easily
• agitated, feeling touchy, or easily annoyed
• poor sleep (unable to fall or stay asleep)
• uneasy or fidgety
• unable to sustain focus, tendency to drift
• tense or clenched muscles

The symptoms must substantially affect the patient’s ability to function professionally or socially. The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern, and the concern is not due to a more appropriate psychiatric condition such as panic attacks (i.e., panic disorder), past trauma (i.e., posttraumatic stress disorder), gaining weight (i.e., eating disorders), social interactions (i.e., social anxiety disorder), separation from a loved one (i.e., separation anxiety disorder), physical symptoms (i.e., somatic symptom disorder), a specific trigger (i.e., specific phobia), or a recurrent thought (i.e., obsessive-compulsive disorder; APA, 2022).

Social anxiety is terror or significant concern about a certain environment that exposes the patient to potential judgment by the public or individuals. This may be when being watched (e.g., during observations, dining in public spaces), presenting (e.g., public speaking), or socializing (e.g., talking or interacting with new people). The patient is concerned that they will behave poorly and be judged by others (i.e., they will be rejected and mortified). The patient reports sudden terror or significant concern whenever exposed to the certain environment. The patient evades the certain environment. The actual risk or threat posed by the environment is insignificant compared to the patient’s emotional response and concern. The terror or concern is consistent for at least 6 months. The terror/concern or active evasion of the environment leads to dysfunction (academic, professional, social, or otherwise) or substantial anguish. The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern, and the concern is not due to a more appropriate psychiatric condition such as autism spectrum disorder, panic attacks (i.e., panic disorder), past trauma (i.e., posttraumatic stress disorder), separation from a loved one (i.e., separation anxiety disorder), a specific trigger (i.e., specific phobia), physical judgment (i.e., body dysmorphic disorder), or a recurrent thought (i.e., obsessive-compulsive disorder). In pediatric patients, the terror/concern must be present when interacting with peers (not only grown-ups) and may present as dependence, immobility, mutism, outbursts, or fits. The terror/concern is disproportionate or unconnected in those with a physical attribute that causes discomfort (e.g., significant scars, facial or other obvious physical differences). The diagnosis may specify performance only if applicable (APA, 2022).

Patients with panic disorder will exhibit panic attacks or unanticipated and sudden experiences characterized by an upwelling of terror that crests quickly (i.e., minutes) and is accompanied by more than three of the following sensations or physiologic reactions:

• perspiration
• difficulty breathing
• angina or chest tightness
• feeling unstable, fuzzy, woozy, or lightheaded
• tachycardia or a subjective feeling like your heart is pounding
• tremors or quivering
• globus sensation or dysphagia
• abdominal discomfort or feeling nauseous
• temperature dysregulation (feeling very hot or cold)
• concern that you may not survive/live
• concern that you are no longer in control or no longer sane
• a sense that the people and things around you are not real (derealization) or that you are not in your body (depersonalization)
• altered sensation (tingling) or a lack of feeling (numbness), especially in the extremities

Following at least one of the patient’s panic attacks, they reported at least 30 days of either:

• a substantial and inappropriate adjustment in activity to prevent the occurrence of another panic attack (e.g., not driving)
• consistent preoccupation or anxiety about experiencing another panic attack or the direct effects of an attack

The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern and are not due to a more appropriate psychiatric condition. The attacks are not more appropriately attributed to past trauma (i.e., posttraumatic stress disorder), social interactions (i.e., social anxiety disorder), separation from a loved one (i.e., separation anxiety disorder), a specific trigger (i.e., specific phobia), or a recurrent thought (i.e., obsessive-compulsive disorder; APA, 2022).

Agoraphobia is defined as terror or significant concern about at least two of the following conditions:

• entering public places that are not confined (e.g., parks/fields, vacant lots, etc.)
• entering indoor spaces (e.g., conference rooms, stores, etc.)
• entering an area with lots of people, or waiting in a queue
• public transportation utilization
• leaving their house without anyone else, such as a companion or partner

The terror/concern is related to becoming trapped or unable to leave or get assistance if the patient were to become frightened, hurt, or otherwise uncomfortable (e.g., losing control of bowel or bladder, getting injured/falling, etc.). The patient reports sudden terror or significant concern almost every time they are presented with the above conditions. The terror/concern or active evasion of the condition leads to dysfunction (academic, professional, social, or otherwise) or substantial anguish. The patient evades the conditions or requires an acquaintance/attendant. The actual risk or threat posed by the condition is insignificant compared to the patient’s emotional response and concern. The terror or concern is consistent for at least 6 months. If there is a comorbid diagnosis (e.g., irritable bowel syndrome, multiple sclerosis) related to the patient’s concern, it is disproportionate and extreme. The symptoms are not due to a more appropriate psychiatric condition such as a specific phobia, past trauma (i.e., posttraumatic stress disorder), flaws in physical appearance (i.e., body dysmorphic disorder), social interactions (i.e., social anxiety disorder), separation from a loved one (i.e., separation anxiety disorder), or a recurrent thought (i.e., obsessive-compulsive disorder). If the patient also experiences panic attacks and meets the required characteristics of panic disorder, the patient may be diagnosed with both (APA, 2022).

Patients with OCD typically exhibit obsessions: repeated and consistent ideations, contemplations, or visions that are considered invasive, unpleasant, and/or not desired and lead to intense concern or anguish. The patient sometimes tries to avoid, subdue, or distract themselves from these contemplations or visions by carrying out a particular behavior. Compulsions are ritualistic physical or intellectual actions that the patient is compelled to complete due to a strict internal expectation or regulation, or related to an obsession, as defined above. These rituals are intended to avoid an undesired consequence or condition or to reduce concern or anguish but are obviously extreme or not logically related to that purpose. In pediatric patients, this intent is not always conscious. These account for significant amounts of the patient’s time during the day (e.g., at least 60 minutes), cause substantial anguish, or drastically affect the patient’s ability to function professionally, socially, or mentally. The condition may be rated as having good, fair, poor, or absent insight; the condition may also be related to a tic disorder (APA, 2022, Boland et al., 2021). There are several screening tools available for the assessment of OCD. The Yale-Brown Obsessive Compulsive Scale (YBOCS) contains a symptom checklist and a scale for assessment of the severity of symptoms. The Obsessive-Compulsive Inventory (OCI) is a 43-item questionnaire, and the Obsessive-Compulsive Inventory-Revised (OCI-R) is an 18-item questionnaire. The Dimensional Obsessive-Compulsive scale (DOCS) is a 20-item questionnaire, and the OCI-4 is a 4-item ultra-brief version of the OCI-R that can be utilized as a rapid screen (Abramovitch et al., 2021).

PTSD symptoms are related to a prior experience of potential or genuine fatality, severe harm, or sexual assault. The patient may have been a participant, victim, or witness/bystander. Alternately, in the case of violent acts, the patient may have learned about a loved one’s experience as a victim or participant or had recurrent professional experiences with unsettling or unpleasant details (e.g., law enforcement officers, social workers, first responders, etc.). Professional experiences typically occur first-hand, not through images, videos, etc. The unwanted and unpleasant symptoms begin after the initial traumatizing experience, last for at least 30 days, and may include:

• recollections of the initial traumatizing experience that are repeated, compulsory, and anguishing/unpleasant (in older pediatric patients, this may include play scenarios resembling the experience in some aspect)
• significant psychological reactions to environmental or inner triggers associated with the initial traumatizing experience
• significant physical responses to environmental or inner triggers associated with the initial traumatizing experience
• flashbacks, during which the patient temporarily mentally disconnects from their current environment and reality and has the sensation that the initial traumatizing experience is happening again
• repetitious nightmares associated with the initial traumatizing experience

The patient consistently prevents exposure to internal or external triggers related to the initial traumatizing experience by performing at least one of the following

• not allowing oneself to think, feel, or remember the initial traumatizing experience or things related to the experience
• preventing exposure to things (e.g., locations, items, persons) that may provoke thinking, feeling, or remembering the initial traumatizing experience

The patient experiences a significant decline in disposition and mental function following the initial traumatizing experience, observed through at least two of the following:

• consistent and extreme negative opinions or outlooks regarding the world, people, and themselves (e.g., people are not to be trusted, the world is not safe, I am damaged permanently)
• consistent predominance of undesirable feelings (e.g., rage, terror, remorse, disgrace)
• lack of closeness or connection with those around them
• lack of memory regarding a crucial portion of the initial traumatizing experience
• faulty thought pattern regarding the reason for or the repercussions of the initial traumatizing experience, leading to a sense of guilt directed at themselves or someone else
• significantly decreased desire for or engagement in substantial events
• consistent paucity of desirable feelings (e.g., joy, love, contentment)

The patient experiences a significant change in responsiveness following the initial traumatizing experience, observed through at least two of the following:

• unsafe or self-harming actions
• extreme edginess or precariously startled
• poor ability to initiate or maintain adequate sleep
• cantankerous disposition with frequent gratuitous fits of rage exhibited as loud outbursts or outwardly aggressive behavior
• behavior that is overly cautious and alert
• challenges maintaining focus

The symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern. The symptoms cause substantial anguish or drastically affect the patient’s ability to function professionally and socially (APA, 2022).

In patients under age 6, the symptoms are related to a prior experience of potential or genuine fatality, severe harm, or sexual assault. The patient may have been a participant, victim, or witness/bystander. Alternately, in the case of violent acts, the patient may have learned about a caregiver’s experience as a victim or participant. The same five unwanted and unpleasant symptoms described above begin after the initial traumatizing experience and last for at least 30 days. In younger pediatric patients, recollections of the initial traumatizing experience may be displayed outwardly through play. The child consistently prevents exposure to external triggers, such as locations, items, persons, behaviors, discussions, or situations, that may provoke memories of the initial traumatizing experience, or they experience a significant decline in disposition and mental function following the initial traumatizing experience, observed through at least two of the following:

• consistent predominance of undesirable feelings (e.g., rage, terror, remorse, disgrace)
• consistent paucity of desirable feelings (e.g., joy, love, contentment)
• lack of social interaction
• significantly decreased desire for or engagement in substantial events, including play

The child experiences a significant change in responsiveness following the initial traumatizing experience, observed through at least two of the following:

• extreme edginess or precariously startled
• poor ability to initiate or maintain adequate sleep
• cantankerous disposition with frequent gratuitous fits of rage exhibited as loud outbursts or outwardly aggressive behavior
• behavior that is overly cautious and alert
• challenges maintaining focus

The symptoms cause substantial anguish or drastically affect the child’s ability to relate with family, friends, or others or function academically. The symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern (APA, 2022).

The diagnosis of PTSD may indicate whether dissociative symptoms of derealization (i.e., belief that the patient’s experienced environment is not real) or depersonalization (i.e., a lack of attachment to their own body or thoughts as if watching from a distance) are present and unrelated to medication, substance, or another medical condition. The diagnosis of PTSD may indicate a delayed expression due to a period of 6 months or more from the initial traumatizing experience and the initial symptom presentation (APA, 2022). Validated screening tools available to assist in the assessment of PTSD are the PTSD Checklist for DSM-5 (PCL-5) and Trauma Symptom Checklist – 40 (Boland et al., 2021).

A complete blood count (CBC), thyroid panel, vitamin B12 level, and toxicology screen are helpful laboratory studies to rule out any medical conditions that may be causing symptoms related to GAD, PTSD, and OCD (Mann & Marwaha, 2022).

Management

Nonpharmacological Treatment of Anxiety Disorders

Cognitive behavioral therapy (CBT) is an effective psychotherapy for individuals with anxiety disorders. CBT teaches individuals methods of rethinking, responding, and reacting to situations to feel less anxious and fearful. CBT is the gold standard for psychotherapy. Exposure therapy is a form of CBT utilized to treat certain anxiety disorders. Exposure therapy enhances individuals’ ability to confront the fears underlying their anxiety disorder and re-engages in activities they have been avoiding, as seen in phobias (NIMH, 2022). Virtual therapy uses computer programs to treat agoraphobia and social anxiety disorder. Patients are provided with a virtual environment, like the environment responsible for their phobia. They identify with the specific avatars during multiple sessions until they can cope with the anxiety while preparing for exposure in real life (Boland et al., 2021). Additional nonpharmacological treatments include lifestyle changes such as avoiding the consumption of excessive amounts of caffeine, reducing or avoiding alcohol consumption, smoking cessation, and incorporating stress management techniques, such as meditation, exercise, and mindfulness, which can help reduce anxiety symptoms and complement the effects of psychotherapy (NIMH, 2022).

Clinical guidelines suggest psychotherapy as a first-line treatment for OCD. Exposure and response prevention (ERP) is an effective therapy for patients with OCD. Medication is also recommended for patients with severe OCD as a first-line treatment. Evidence shows that the combination of psychotherapy and pharmacotherapy is very effective (Boland et al., 2021). Another treatment option that is exceptionally successful in patients with OCD is deep brain stimulation (DBS), which involves placing electrodes in targeted areas of the brain. Impulses are then sent through the electrodes to help regulate brain activity (NIMH, 2019). Encouraging patients to express and verbalize thoughts is essential when managing OCD, as well as developing a good rapport with the patient. Clinicians must work with the patient to reduce anxiety related to completing or not completing compulsions and increase coping mechanisms to interrupt or stop intrusive thoughts or compulsions (Skapinakis et al., 2019).

Several therapies have been shown to have positive results for patients with PTSD. Trauma-focused cognitive-behavioral therapy (TFCBT) involves prolonged exposure (PE) therapy. PE focuses on reexperiencing the traumatic event through repeatedly engaging with the memories and everyday reminders instead of avoiding triggers. Eye movement desensitization and reprocessing therapy (EMDR) involves repeatedly recalling distressing images while receiving sensory inputs. Cognitive processing therapy (CPT) emphasizes correcting faulty attributions and posttraumatic overgeneralizing the world as dangerous and uncontrollable. Present-centered therapy (PCT) focuses on the current relationship and work challenges rather than the trauma. Psychodynamic psychotherapy may also be useful in the treatment of many patients with PTSD (Boland et al., 2021). PTSD is a trauma-related disorder, so it is not always comfortable for patients to communicate and openly express their feelings. Therefore, it is imperative for clinicians, nurses, and other healthcare professionals to be knowledgeable about the signs and symptoms of PTSD. Studies have shown patients have a more favorable outcome with early detection and implementation of treatment (Mann & Marwaha, 2022).

The APRN must evaluate patients at risk who show signs of being abused, follow proper facility protocol, and make appropriate referrals to maintain the safety of the patient and their children (Paul, 2018). Particular attention should be given to the fact that these clients may have to maintain contact with their abuser if they have children together. The APRN should provide the patient with all the necessary resources and information to remain safe and continue to work towards recovering from the abuse and treating the resulting PTSD (Laing et al., 2018). APRNs should incorporate methods to develop a trusting relationship with the patient to communicate effectively (Paintain & Cassidy, 2018). Patients with PTSD require a calm and therapeutic environment that encourages the expression of feelings and fears and incorporates different therapies to benefit the patient. The APRN can assist the patient in identifying triggers or situations that may cause recurrent memories or flashbacks, developing coping mechanisms and methods to help reduce intrusive thoughts or memories, encouraging group participation and therapy, and discussing ways to desensitize the patient from the traumatic event.

Pharmacological Treatment for Anxiety Disorders

The first-line agent for generalized anxiety disorder, panic disorder, and social anxiety disorder is an SSRI that selectively inhibits serotonin reuptake and affects the GABA system. These medications are well tolerated and do not cause dependency. Commonly prescribed SSRIs and dosages are fluoxetine (Prozac) 20mg - 80mg a day, sertraline (Zoloft) 50mg - 200mg a day, citalopram (Celexa) 20mg - 60mg a day, paroxetine (Paxil) 20mg – 50mg a day, and escitalopram (Lexapro) 10mg – 20mg a day. Selection should be based on the side effect profile, patient preference, patient history, and drug interactions. Potential side effects of SSRIs include but are not limited to nausea, vomiting, diarrhea, headache, dizziness, dry mouth, drowsiness, insomnia, agitation, anxiety, sexual dysfunction, sweating, appetite/weight changes, and restlessness (see Table 1). Venlafaxine can also cause hypertension. It is essential to discuss with patients that many side effects are transient and will resolve within weeks. Patient education should include the importance of not abruptly stopping medications to prevent serotonin discontinuation syndrome. Patients should be aware of the effects of abruptly discontinuing an SSRI, such as disequilibrium, nausea, increased agitation, headache, flu-like symptoms, insomnia, diarrhea, and an increased feeling of being dissatisfied with life (Craske & Bystritsky, 2021; Hutchinson, 2015).

Table 1

Common Side Effects of SSRIs and SNRIs

 

	SSRIs	SNRIs
Possible Side Effects	Nausea, vomiting, diarrhea, headache, dry mouth, drowsiness, insomnia, nervousness, agitation, restlessness, sexual dysfunction, appetite change leading to weight loss or weight gain	Nausea, headache, dizziness, excessive sweating, dry mouth, tiredness, constipation, insomnia, sexual dysfunction, anorexia
Warnings and Monitoring	Serotonin syndrome; suicide risk; risk for withdrawal symptoms if stopped abruptly	Serotonin syndrome; suicide risk; risk for withdrawal symptoms if stopped abruptly

 (Mayo Clinic, 2019)

The APRN should assess for signs and symptoms of serotonin syndrome, excess serotonin in the brain that can be life-threatening. Symptoms of serotonin syndrome include restlessness, high fever, sweating, tremors, lack of coordination, delirium, rigidity, rapid changes in blood pressure, tachycardia, coma, and possible death (Mayo Clinic, 2019). While antidepressants typically do not require routine laboratory monitoring or drug levels, prescribers should remain alert to the potential side and adverse effects outlined in the table above. Further, SSRIs are rarely associated with hyponatremia, bleeding, and a decline in bone density. Prescribers should perform a routine evaluation of patients on SSRIs and consider ordering laboratory testing to evaluate for hyponatremia if patients experience any associated medical complications. Bleeding events in patients on SSRI therapy most commonly present as GI bleeding, although this is rare. Patients prescribed venlafaxine XR (Effexor XR) should have their blood pressure checked at baseline and then periodically after starting and following any dose increase to evaluate for hypertension. The risk for hypertension with this medication is dose-dependent and heightens with dose levels of 225 mg or higher. Patients taking duloxetine (Cymbalta) should have their liver function tests evaluated about once annually due to the low risk of alanine transaminase levels. Before prescribing tricyclic antidepressants (TCAs), patients should be assessed for the presence of any cardiac history, and a baseline electrocardiogram (ECG) should be performed. ECG should be performed again once the therapeutic dose is achieved (Terrery, 2016).

The SNRIs venlafaxine (Effexor) 75-150 mg and duloxetine (Cymbalta) 30-90 mg are also effective for anxiety (Gregory & Hardy, 2021). Hydroxyzine pamoate (Vistaril) 25 mg -100 mg is a sedating antihistamine that can be used as an alternative to benzodiazepines for the acute treatment of GAD. Buspirone (Buspar) 10-30 mg twice a day is an azapirone that is also effective for treating GAD. Additional pharmacological treatments of GAD include benzodiazepines that are recommended for use as an adjunct to SSRIs during initial treatment or stabilization in an acute phase of anxiety and only for short-term use (Boland et al., 2021; Gregory & Hardy, 2021). Patients with a history of alcoholism or substance use disorders are not candidates for benzodiazepines due to the risk of misuse and dependence (Munir et al., 2022).

The recommended first-line treatments for SAD are SSRIs or SNRIs (Boland et al., 2021). The SSRIs paroxetine (Paxil) and sertraline (Zoloft) are recommended (Mayo Clinic, 2021). In addition, β-blockers such as propranolol (Inderal) 10-20 mg may be helpful for performance anxiety. However, they are not indicated for other types of social anxiety (Boland et al., 2021; Gregory & Hardy, 2021).

PD is treated with SSRIs and SNRIs as the first-line drug choice; TCAs and monoamine oxidase inhibitors (MAOIs) are adequate but not favored for use. The Food and Drug Administration (FDA) approved fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and the SNRI venlafaxine (Effexor) for the treatment of PD. In addition, the TCA mirtazapine (Remeron) 15 – 45 mg every night is a noradrenergic and specific serotonin agent for treating depression with anxiety and insomnia that is indicated as a second-line treatment option for PD (Boland et al., 2021).

Psychopharmacology treatments for agoraphobia involve SSRIs, which are generally first-line therapy. SNRIs, TCAs, or benzodiazepines may be considered as alternatives (Balaram & Marwaha, 2022).

In the past, the TCA clomipramine (Anafranil) was used as the first-line therapy for OCD; however, because of the significant side effects, the SSRIs fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) are now the first-line treatment for OCD. When used for the treatment of OCD, these SSRIs must be prescribed at higher doses than those recommended for depression (Brock & Hany, 2020).

Patients with PTSD may be prescribed SSRIs, particularly sertraline (Zoloft) and paroxetine (Paxil). Other medications that have been effective in treating PTSD are the SNRI venlafaxine (Effexor), the atypical antipsychotic risperidone (Risperdal), and the anticonvulsant topiramate (Topamax). Prazosin (Minipress) may help decrease or eliminate the nightmares associated with PTSD. A low dose of trazodone may also be prescribed to treat insomnia (Boland et al., 2021).

Future Research/Directions

GAD is a chronic disorder that can be debilitating. There are currently several nonpharmacological and pharmacological treatments recommended for GAD. Approximately half of the patients treated for GAD fail initial treatment, resulting in treatment-resistant (or refractory) GAD. Treatment–refractory GAD is characterized as failure to respond to at least one trial of a first-line pharmacological agent (Ansara, 2020). Studies are currently being conducted to examine the effectiveness of new medications that may result in additional options for treating anxiety. However, these newer medications may not replace current treatments but may be used as adjuncts. Researchers have noted the lack of efficient development of better biomarkers (Garakani et al., 2020).

Future research should incorporate more brain imaging, pharmacogenomic, and other neurobiochemical advances to further the advancement of treatment (Garakani et al., 2020). Research should also be directed to identifying the causes of anxiety and panic attacks and ways to reduce and treat symptoms related to anxiety disorders. The use of positive psychological interventions to reduce anxiety should be investigated; nonpharmacological methods can often dramatically improve patient outcomes more than certain medications, especially short-term medications (Brown et al., 2019). CBT remains the first-line psychological treatment for most anxiety disorders and is effective with short- and long-term treatment plans. Emerging treatments that have shown to be effective when augmented with CBT are exposure therapy with virtual reality, augmentation with mindfulness, and emotional regulation strategies (Reddy et al., 2020). There will continue to be a constant influx of new techniques for treating mental health illnesses. Clinicians, nurses, and healthcare professionals should remain open-minded about new treatments. When patients express interest in new treatments (whether FDA-approved or off-label), we are responsible for educating them about the risks, benefits, and limitations and openly evaluating the appropriateness of treatment as it relates specifically to the patient's symptoms (OR, 2019).

Conclusion

Anxiety disorders include GAD, SAD, PD, separation anxiety disorder, selective mutism, phobias, PTSD, and OCD; these are the 6^th leading cause of disability and the most common mental health disorder worldwide. Anxiety disorders are chronic and can impair an individual’s ability to function and overall quality of life (Zimmermann et al., 2020). Evidence-based practice has proven psychopharmacology and psychotherapy effective in treating anxiety disorders. The effectiveness of treatment may vary depending on the severity of the symptoms, leading to treatment-resistant anxiety (Penninx et al., 2021). Research has also shown additional therapies, such as meditation, mindfulness, and yoga, to treat anxiety effectively. It is crucial for clinicians and nursing staff to be familiar with the signs and symptoms of anxiety, as some can manifest physically. It is equally important to educate patients about the different treatment options, both pharmacologic and nonpharmacologic (Brahmbhatt et al., 2021). Psychiatric care is centered on developing a therapeutic relationship between the patient and the care provider. It is essential for nurses and other healthcare professionals to care for patients with GAD calmly and positively, promoting positive nurse-patient interactions (Kaçmaz & Çam, 2019).

References

Abramovitch, A., Abramowitz, J. S., & McKay, D. (2021). The OCI-4: An ultra-brief screening scale for obsessive-compulsive disorder. Journal of Anxiety Disorders, 78, 102354. https://doi.org/10.1016/j.janxdis.2021.102354

Adwas, A. A., Jbireal, J. M., & Azab, A. E. (2019). Anxiety: Insights into signs, symptoms, etiology, pathophysiology, and treatment. East African Scholars Journal of Medical Sciences, 2(10), 580-591

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5^th ed., text rev.) (DSM-5-TR). https://doi.org/10.1176/appi.books.9780890425787

Ansara, E. D. (2020). Management of treatment-resistant generalized anxiety disorder. The Mental Health Clinician, 10(6), 326–334. https://doi.org/10.9740/mhc.2020.11.326

Antoniadou, N., Kokkinos, C. M., & Markos, A. (2019). Psychopathic traits and social anxiety in cyber-space: A context-dependent theoretical framework explaining online disinhibition. Computers in Human Behavior, 99, 228–234. https://doi.org/10.1016/j.chb.2019.05.025

Balaram, K., & Marwaha, R. (2022). Agoraphobia. In StatPearls [Internet]. StatPearls Publishing. PMID: 32119274

Bandelow, B., Michaelis, S., & Wedekind, D. (2022). Treatment of anxiety disorders. Dialogues in Clinical Neuroscience. https://doi.org/10.31887/DCNS.2015.17.3/bbandelow

Boland, R. J., Verduin, M. L., Ruiz, P., Shah, A., & Sadock, B. J. (2021). Kaplan & Sadock's synopsis of psychiatry (12^th ed). Wolters Kluwer

Brahmbhatt, A., Richardson, L., & Prajapati, S. (2021). Identifying and managing anxiety disorders in primary care. The Journal for Nurse Practitioners, 17(1), 18-25. https://doi.org/10.1016/j.nurpra.2020.10.019

Brock, H, & Hany, M. (2021). Obsessive-compulsive disorder. StatPearls Publishing, PMID: 31985955.

Brown, L., Ospina, J. P., Celano, C. M., & Huffman, J. C. (2019). The effects of positive psychological interventions on medical patients' anxiety: A meta-analysis. Psychosomatic Medicine, 81(7), 595–602. https://doi.org/10.1097/PSY.0000000000000722

Chand, S. P., Marwaha, R., & Bender, R. M. (2022). Anxiety (nursing). In StatPearls [Internet]. StatPearls Publishing.

Craske, M & Bystritsky, A. (2021). Generalized anxiety disorder in adults: Management. Retrieved November 16, 2022, from https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-management

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49-ITC64. https://doi.org/10.7326/AITC201904020

Denke, L., & Denham, S. A. (2019). Family-focused treatments for veterans with posttraumatic stress disorder. Medsurg Nursing, 28(4), 235–242.

D’Errico, L., Call, M., Blanck, P., Vonderlin, E., Bents, H., & Mander, J. (2019). Associations between mindfulness and general change mechanisms in individual therapy: Secondary results of a randomized controlled trial. Counselling & Psychotherapy Research, 19(4), 419–430. https://doi.org/10.1002/capr.12233

Eilert, N., Enrique, A., Wogan, R., Mooney, O., Timulak, L., & Richards, D. (2021). The effectiveness of Internet‐delivered treatment for generalized anxiety disorder: An updated systematic review and meta‐analysis. Depression and Anxiety, 38(2), 196-219. https://doi.org/10.1002/da.23115

Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in Psychiatry, 1412. https://doi.org/10.3389/fpsyt.2020.595584

Gregory, A. & Hardy, L. (2021). Anxiety in primary care: A primer for APRNs. https://www.myamericannurse.com/anxiety-disorders-in-primary-care/

Guess, K. E., Fifolt, M., Adams, R. C., Ford, E. W., & McCormick, L. C. (2019). Life after trauma: A survey of level 1 trauma centers regarding posttraumatic stress disorder and acute stress disorder. Journal of Trauma Nursing, 26(5), 223–233. https://doi.org/10.1097/JTN.0000000000000451

Gupta, A., Khanna, S., & Jain, R. (2019). Deep brain stimulation of ventral internal capsule for refractory obsessive-compulsive disorder. Indian Journal of Psychiatry, 61(5), 532–536. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_222_16

Harnett, N. G., Goodman, A. M., & Knight, D. C. (2020). PTSD-related neuroimaging abnormalities in brain function, structure, and biochemistry. Experimental Neurology, 330, 113331. https://doi.org/10.1016/j.expneurol.2020.113331

Ironside, M., Browning, M., Ansari, T.L., Harvey, C.J., Sekyi-Djan, M.N., Bishop, S.J., Harmer, C.J., & O'Shea, J. (2019). Effect of prefrontal cortex stimulation on regulation of amygdala response to threat in individuals with trait anxiety: A randomized clinical trial. JAMA Psychiatry, 76(1), 71–78. https://doi.org/10.1001/jamapsychiatry.2018.2172

Kaçmaz, E. D., & Çam, M. O. (2019). Review of caring nurse-patient interaction for nurses caring for psychiatric patients. Journal of Psychiatric Nursing, 10(1), 65-74. https://doi.org/10.14744/phd.2018.83702

Laing, L., Heward-Belle, S., & Toivonen, C. (2018). Practitioner perspectives on collaboration across domestic violence, child protection, and family law: Who's minding the gap? Australian Social Work, 71(2), 215–227. https://doi.org/10.1080/0312407X.2017.1422528

Mann, S.K., & Marwaha, R. (2022). Posttraumatic stress disorder. In: StatPearls [Internet].

Martin-Cuellar, A., Lardier, D. T., Atencio, D. J., Kelly, R. J., & Montañez, M. (2019). Vitality as a moderator of clinician history of trauma and compassion fatigue. Contemporary Family Therapy: An International Journal, 41(4), 408–419. https://doi.org/10.1007/s10591-019-09508-7

Mayo Clinic. (2019). Serotonin and norepinephrine reuptake inhibitors (SNRIs). https://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20044970

Munir, S., Takov, V., & Coletti, V. A. (2022). Generalized anxiety disorder (nursing). In StatPearls [Internet]. StatPearls Publishing

Nielsen, S. K. K., Hageman, I., Petersen, A., Daniel, S. I. F., Lau, M., Winding, C.,…Vangkilde, S. (2019). Do emotion regulation, attentional control, and attachment style predict response to cognitive behavioral therapy for anxiety disorders? – an investigation in clinical settings. Psychotherapy Research, 29(8), 999–1009. https://doi.org/10.1080/10503307.2018.1425933

National Alliance on Mental Illness. (2017). Anxiety disorder. https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Anxiety-Disorders

National Institute of Mental Health. (2022). Anxiety disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders

Nierengarten, M. B. (2019). Anxiety disorders in primary care. Contemporary Pediatrics, 36(10), 23-26

Nursing Times. (2020). Symptoms and causes of anxiety and its diagnosis and management. Retrieved from https://www.nursingtimes.net/roles/mental-health-nurses/symptoms-and-causes-of-anxiety-and-its-diagnosis-and-management-08-09-2020/

Ohi, K., Kuramitsu, A., Fujikane, D., Takai, K., Sugiyama, S., & Shioiri, T. (2022). Shared genetic basis between reproductive behaviors and anxiety-related disorders. Molecular Psychiatry, 1-10. https://doi.org/10.1038/s41380-022-01667-8

OR, A. Q. (2019). 'Miracle cures' in psychiatry? Current Psychiatry, 18(9), 13.

Paintain, E., & Cassidy, S. (2018). First‐line therapy for posttraumatic stress disorder: A systematic review of cognitive behavioral therapy and psychodynamic approaches. Counselling & Psychotherapy Research, 18(3), 237–250. https://doi.org/10.1002/capr.12174

Paul, O. (2019). Perceptions of family relationships and posttraumatic stress symptoms of children exposed to domestic violence. Journal of Family Violence, 34(4), 331–343. Doi-org.wa.opal-libraries.org/10.1007/s10896-018-00033-z

Penninx, B. W., Pine, D. S., Holmes, E. A., & Reif, A. (2021). Anxiety disorders. The Lancet (British Edition), 397(10277), 914-927. https://doi.org/10.1016/S0140-6736(21)00359-7

Reddy, Y., Sudhir, P. M., Manjula, M., Arumugham, S. S., & Narayanaswamy, J. C. (2020). Clinical practice guidelines for cognitive-behavioral therapies in anxiety disorders and obsessive-compulsive and related disorders. Indian Journal of Psychiatry, 62(Suppl 2), S230–S250. https://doi.org/10.4103/psychiatry.IndianJPsychiatry77319

Scott, A. (2019). PTSD. Community Practitioner, 92(5), 30–35.

Skapinakis, P., Politis, S., Karampas, A., Petrikis, P., & Mavreas, V. (2019). Prevalence, comorbidity, quality of life and use of services of obsessive-compulsive disorder and subthreshold obsessive-compulsive symptoms in the general adult population of Greece. International Journal of Psychiatry in Clinical Practice, 23(3), 215–224. https://doi.org/10.1080/13651501.2019.1588327

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. Deutsches Ärzteblatt International, 115(37), 611-620.

Terrery, C. L., & Nicoteri, J. A. (2016). The 2015 American Geriatric Society Beers Criteria: Implications for nurse practitioners. The Journal for Nurse Practitioners, 12(3), 192-200. https://doi.org/10.1016/j.nurpra.2015.11.027

Yildirim, A., & Boysan, M. (2019). A theoretical integration within obsessive-compulsive disorder (OCD) and dissociative spectrums: Obsessional dissociation. Sleep & Hypnosis, 21(1), 23-37. https://doi.org/10.5350/Sleep.Hypn.2019.21.0169

 Zimmermann, M., Chong, A. K., Vechiu, C., & Papa, A. (2020). Modifiable risk and protective factors for anxiety disorders among adults: A systematic review. Psychiatry Research, 285, 112705. https://doi.org/10.1016/j.psychres.2019.112705